Stream: CCDA / FHIR mapping stream
Topic: Mapping document from EHR-toFHIR
Roney A (May 21 2019 at 00:26):
Is there a mapping document from EHR (ERD model)-to-FHIR_mappings with ERD relationships transformed to FHIR Resource elements and maintain all the FHIR multiplicity / cardinality? Is there a spreadsheet of all FHIR 4.0 data elements?
Lloyd McKenzie (May 21 2019 at 01:01):
Every EHR is different, so there can't be a generic mapping document. And some resources may map to numerous different EHR constructs (e.g. Lab which covers vitals, lab, clinical assessments, nursing data and a bunch of other stuff. Every EHR vendor thus has to do their own mappings (and continue to evolve those as FHIR evolves and/or as additional implementation guides are developed that refine what data is expected to appear where).
We don't generate an Excel spreadsheet that covers all the resources (or any of them, actually), but it would be pretty straightforward to take the profiles-structures.xml Bundle and write a small transform that would spit out a CSV you could use as a basis for such a spreadsheet. If you wanted to you could use the profiles-types.xml as well to expand the different complex data types.
Grahame Grieve (May 21 2019 at 01:22):
well, i've been meaning to get around to this, so:
- http://hl7.org/fhir/definitions.xlsx.r4.zip
- http://hl7.org/fhir/STU3/definitions.xlsx.r3.zip
- http://hl7.org/fhir/DSTU2/definitions.xlsx.r2.zip
Roney A (May 21 2019 at 16:53):
Every EHR is different, so there can't be a generic mapping document. And some resources may map to numerous different EHR constructs (e.g. Lab which covers vitals, lab, clinical assessments, nursing data and a bunch of other stuff. Every EHR vendor thus has to do their own mappings (and continue to evolve those as FHIR evolves and/or as additional implementation guides are developed that refine what data is expected to appear where).
We don't generate an Excel spreadsheet that covers all the resources (or any of them, actually), but it would be pretty straightforward to take the profiles-structures.xml Bundle and write a small transform that would spit out a CSV you could use as a basis for such a spreadsheet. If you wanted to you could use the profiles-types.xml as well to expand the different complex data types.
Thank you Lloyd.
Roney A (May 21 2019 at 16:55):
well, i've been meaning to get around to this, so:
Thank you Grahame.
Roney A (May 21 2019 at 20:23):
Every EHR is different, so there can't be a generic mapping document. And some resources may map to numerous different EHR constructs (e.g. Lab which covers vitals, lab, clinical assessments, nursing data and a bunch of other stuff. Every EHR vendor thus has to do their own mappings (and continue to evolve those as FHIR evolves and/or as additional implementation guides are developed that refine what data is expected to appear where).
We don't generate an Excel spreadsheet that covers all the resources (or any of them, actually), but it would be pretty straightforward to take the profiles-structures.xml Bundle and write a small transform that would spit out a CSV you could use as a basis for such a spreadsheet. If you wanted to you could use the profiles-types.xml as well to expand the different complex data types.
Thank you Lloyd.
I guess the question arises, even though not all "resources" may map to the current EHR constructs and vice versa which leads to creation of a FHIR server repository that may not have a 100% match to FHIR specifications (resources, profiles, data types, etc.). Does that still get us to be FHIR CONFORMANT (at least BASE FHIR SPECIFICATION)?
Lloyd McKenzie (May 21 2019 at 20:29):
Yes - EHRs can be FHIR conformant even if they don't have the same capabilities or don't necessarily expose their data in exactly the same way. FHIR IGs may impose additional expectations - such that an EHR might be FHIR-conformant but not conformant with something like the FHIR US-Core implementation guide.
Roney A (May 21 2019 at 21:04):
Yes - EHRs can be FHIR conformant even if they don't have the same capabilities or don't necessarily expose their data in exactly the same way. FHIR IGs may impose additional expectations - such that an EHR might be FHIR-conformant but not conformant with something like the FHIR US-Core implementation guide.
Thank you Lloyd. That makes sense. In other words, in addition to EHR, I may have 100's of healthcare analytics running based on user defined metrics derived from several EHR data sources (non-FHIR standards) by mapping those EHR data source elements that is found to be a match with FHIR R4 resources and profiles, etc.). EHR elements that no match found in FHIR, is followed by creating FHIR extension, and they can still be FHIR Compliant (conformant). I am assuming that is correct? Finally, who (person(s)) or what FHIR committee's or FHIR council's we need to go through to get the FHIR conformant statement of interoperability? Is there an FHIR email address or contacts for the FHIR compliance folks? How do we as a company can PUBLISH A FHIR CAPABILITY STATEMENT?
Lloyd McKenzie (May 21 2019 at 22:01):
Anyone can publish a FHIR capability statement. There's no vetting or certification process through HL7. A few organizations have certification processes for adherence to certain IGs (e.g. IHE), but by and large, the onus for verifying adherence to declarations of FHIR conformance fall on those who want to use the system.
Roney A (May 21 2019 at 22:09):
Anyone can publish a FHIR capability statement. There's no vetting or certification process through HL7. A few organizations have certification processes for adherence to certain IGs (e.g. IHE), but by and large, the onus for verifying adherence to declarations of FHIR conformance fall on those who want to use the system.
Thank you Lloyd. That's very helpful.
Lloyd McKenzie (May 21 2019 at 22:16):
That doesn't mean there won't be more certification processes in the future. However, any such processes will likely be centered around IGs.
Roney A (Jun 03 2019 at 16:16):
Thank you Lloyd. Is there a specific "storage"requirement for FHIR Server deployment? Can we deploy FHIR server on NoSQL vs Relational (SQL) vs mongodb vs cassandra storage? Also is there a preference, XML vs JSON APIs?
Lloyd McKenzie (Jun 03 2019 at 18:17):
No storage technology requirement - there are production systems using a wide variety of approaches. In terms of API, the general recommendation is that servers should support all of the syntaxes (ideally even including RDF) as that maximizes the number of client systems that can talk to you. The reference implementations provide syntax conversion, so there's rarely a good reason to constrain what syntaxes you permit.
Roney A (Jun 04 2019 at 14:19):
No storage technology requirement - there are production systems using a wide variety of approaches. In terms of API, the general recommendation is that servers should support all of the syntaxes (ideally even including RDF) as that maximizes the number of client systems that can talk to you. The reference implementations provide syntax conversion, so there's rarely a good reason to constrain what syntaxes you permit.
Thank you Lloyd.
Roney A (Jun 05 2019 at 00:54):
Hi Lloyd, what FHIR resource can be mapped to Adjudicated Pharmacy Claim and Pharmacy Benefit Management? I am assuming MedicationAdministration, and Medication Request. Is that correct? Can we map the Claim Identifier to Pharmacy ID/NCPDP Provider ID/Pharmacy NPI? Do we capture claim adjustment in FHIR Resource ClaimResponse? For Dispense as Written (DAW), can we use FHIR Resource MedicationRequest.dispenseRequest? Please let me know, at your earliest convenience. Thank you.
Lloyd McKenzie (Jun 05 2019 at 00:58):
The claim would be Claim and the adjudicated result would be ClaimResponse. Both would point to MedicationRequest and/or MedicationDispense. (they could point to MedicationAdministration for something like Methadone where you actually charge for the administration in addition to the dispense). Can you explain Pharmacy Benefit Management? If it's an explanation of benefit, then look at the ExplainationOfBenefit resource.
Roney A (Jun 05 2019 at 16:33):
The claim would be Claim and the adjudicated result would be ClaimResponse. Both would point to MedicationRequest and/or MedicationDispense. (they could point to MedicationAdministration for something like Methadone where you actually charge for the administration in addition to the dispense). Can you explain Pharmacy Benefit Management? If it's an explanation of benefit, then look at the ExplainationOfBenefit resource.
Thank you Lloyd. PBM, google definition is a pharmacy benefit manager (PBM) is a third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program, and state government employee plans. Express Scripts is an example of a PBM. Another PBM is CVS Caremark, the PBM of CVS Health. OptumRx is another example of PBM.
Lloyd McKenzie (Jun 05 2019 at 17:41):
Ah. If you'd said you were interested in the "manager", I'd have recognized it. A PBM would be an Organization - specifically the Organization pointed to by Claim.insurer
Lloyd McKenzie (Jun 05 2019 at 17:42):
I do agree that the definition could use some work to make it more clear that it's "who should process the claim", not necessarily "who is the holder of the insurance contract". Feel free to submit a change request to get this clarification made (and perhaps to explicitly reference "benefits manager" as a possible allowed value.
Roney A (Jun 05 2019 at 19:19):
Ah. If you'd said you were interested in the "manager", I'd have recognized it. A PBM would be an Organization - specifically the Organization pointed to by Claim.insurer
Thank you Lloyd, it makes sense. Do we have a link for submitting a change request? Will then make a request accordingly.
Lloyd McKenzie (Jun 05 2019 at 19:21):
There's a "propose a change" link at the bottom of every page in the spec. You'll need to register the first time. After that, feel free to note anything that could use clarifying/fixing.
Roney A (Jun 05 2019 at 19:24):
There's a "propose a change" link at the bottom of every page in the spec. You'll need to register the first time. After that, feel free to note anything that could use clarifying/fixing.
Thank you Lloyd for the information. Will do that accordingly.
Roney A (Jun 05 2019 at 21:22):
Hi Lloyd. I did register a moment ago, awaiting confirmation.
Roney A (Jun 14 2019 at 20:30):
Hi Lloyd-
Can't find an appropriate home for the following EHR columns:
1) ATTRIBUTION COLUMNS:
Special need plans (for a member)
Low income subsidy (provided to medicare enrolled low income)
Year and month of attribution
Attribution method
Quarter in which patient is active
2) ATTACHMENT COLUMNS:
local member id
encounter id
provider npi
provider name
practice npi
practice name
attachment name
attachment type
doc type
attachment filepath
Last update date
Last update by
created by
provider id
provider id type
practice id
practice id type
source record date
Author date
Author id
Author name
3) PHARMACY CLAIM
1) No column for dispense as written (DAW)
2) No column for Drug Formulary Tiers (Generic, brand-name, non-preferred brand-name, speciality medications)
3) MedicationDispense.daysSupply - does that imply when dispensed ONLY or at the time of the actual order placed by the prescriber?
4) RESOIURCE COMPARTMENTS
Resource InsurancePlan - Not linked to any defined compartments
4.1 Do we use InsurancePlan.Network to link and reference to Patient, Coverage and Practitioner?
Roney A (Jun 18 2019 at 17:47):
Hi Lloyd-
Can't find an appropriate home for the following EHR columns:1) ATTRIBUTION COLUMNS:
Special need plans (for a member)
Low income subsidy (provided to medicare enrolled low income)
Year and month of attribution
Attribution method
Attribution logic stage
Quarter in which patient is active
Hierarchy id
Attribution start date
Attribution end date
Hospice benefit flag
Eligibility flag - Attribution status of a patient2) ATTACHMENT COLUMNS:
local member id
encounter id
provider npi
provider name
practice npi
practice name
attachment name
attachment type
doc type
attachment filepath
Last update date
Last update by
created by
provider id
provider id type
practice id
practice id type
source record date
Author date
Author id
Author name3) PHARMACY CLAIM
1) No column for dispense as written (DAW)
2) No column for Drug Formulary Tiers (Generic, brand-name, non-preferred brand-name, speciality medications)
3) MedicationDispense.daysSupply - does that imply when dispensed ONLY or at the time of the actual order placed by the prescriber?
4) Date recent refill
5) Refills remaining4) RESOIURCE COMPARTMENTS
Resource InsurancePlan - Not linked to any defined compartments
4.1 Do we use InsurancePlan.Network to link and reference to Patient, Coverage and Practitioner?
Hi Lloyd, could you please provide some clarity on the "ATTRIBUTION" table that is critical. Not able to reference and match FHIR resources like Practitioner, Encounter, Claim, CarePlan, etc. to ATTRIBUTION columns. Would you recommend, submitting a Request for adding a ATTRIBUTION FHIR Resource. Also, there are several gaps in FHIR for Pharmacy Claim and Attachment? Could please provide suggestions and/or options for corresponding FHIR mappings?
Lloyd McKenzie (Jun 18 2019 at 22:47):
For the first set, need definitions (and data types) for these. It's not clear what most of them mean.
For attachment, are you mapping to the Media or DocumentReference resources and looking inside the data types? Note that things like the provider name and practice name will be found in Practitioner and Organization which you'll have to reach by reference.
3. DAW = MedicationRequest.substitutionAllowed=false
Not sure what you mean by Tiers - are you indicating what kind of code is specified or are you specifying substitution rules
MedicationDispense.daysSupply = how much can be dispensed at once as a number of days supply for a single fill
Date of most recent fill is determined by looking at what MedicationDispenses you have. How is it being used on the claim?
Refills remaining - How is it being used on the claim? (Normally you just calculate)
InsurancePlan isn't linked to any compartments - why would it need to be? Generally the Patient coverage would link to the plan. The plan is non-patient-specific.
Roney A (Jun 19 2019 at 16:37):
For the first set, need definitions (and data types) for these. It's not clear what most of them mean.
For attachment, are you mapping to the Media or DocumentReference resources and looking inside the data types? Note that things like the provider name and practice name will be found in Practitioner and Organization which you'll have to reach by reference.
3. DAW = MedicationRequest.substitutionAllowed=false
Not sure what you mean by Tiers - are you indicating what kind of code is specified or are you specifying substitution rules
MedicationDispense.daysSupply = how much can be dispensed at once as a number of days supply for a single fill
Date of most recent fill is determined by looking at what MedicationDispenses you have. How is it being used on the claim?
Refills remaining - How is it being used on the claim? (Normally you just calculate)
InsurancePlan isn't linked to any compartments - why would it need to be? Generally the Patient coverage would link to the plan. The plan is non-patient-specific.
Hi Lloyd- please see below first set of definitions and data types for attribution. Do we have corresponding FHIR resource/element to map to?
Special need plans (for a member) - Definition: Capture if member is having any special need plans, varchar(20)
Low income subsidy (provided to medicare enrolled low income)-Definition: Amount of subsidy provided to medicare enrolled low income, varchar(20)
Year and month of attribution-Definition: Year and Month of attribution, integer
Attribution method-Definition: Payer defined or Clinical Network defined, varchar(50)
Attribution logic stage-Definition:What priority stage in logic is this provider attributed on, integer
Quarter in which patient is active-Definition: The quarter in which the patient is active, varchar(10)
Hierarchy id-Definition: Unique ID of hierarchy in org hierarchy used to define provider and practice attributed to a member this month, varchar(100)
Attribution start date-Definition: Start date of plan, date
Attribution end date-Definition: End date of plan, date
Hospice benefit flag-Definition: Flag to define if patient is enrolled for hospice, varchar(10)
Eligibility flag-Definition: Attribution status of a patient, varchar(10)
Lloyd McKenzie (Jun 19 2019 at 16:55):
@Paul Knapp ?
Roney A (Jun 19 2019 at 20:22):
@Paul Knapp
Hi Paul, could you please address the issue? Are we able to map any of the EHR Attribution Columns to FHIR resource/elements? Do we request a new resource or add as extensions to some existing resource? Please let me know. Thx
Roney A (Jun 21 2019 at 20:40):
Paul Knapp ?
Hi Lloyd, assuming we won't have a timely response from Paul. How do we address non-FHIR resource elements ( EHR Attribution Columns) on an FHIR server? Since there is not a single FHIR resource that captures any or all of the EHR Attribution Columns, we cannot create an extension, else FHIR creates a new ATTRIBUTION resource. In the interim, how do we expose the EHR Attribution Columns to consuming FHIR clients and 3rd party? Use the same EHR Attribution Columns names and mention in the capability statement as non-FHIR complaint elements? Please let me know?
Lloyd McKenzie (Jun 21 2019 at 21:22):
I don't really understand what you mean by attribution. @Andy Stechishin @MaryKay McDaniel?
Roney A (Jun 24 2019 at 22:26):
I don't really understand what you mean by attribution. Andy Stechishin MaryKay McDaniel?
Following is an example of EHR Attribution Columns: (patient attribution, payer attribution columns)
1. Column name: snp_member; Description: Special need plans (for a member)
2. Column name: li_subsidy; Description: Low income subsidy (provided to medicare enrolled low income)
3. Column name: ym_attribution; Description: Year and month of attribution
4. Column name: att_method; Description: Attribution method
5. Column name: qtr_active; Description: Quarter in which patient is active
How do we map the above EHR attribution column names(1-5 ) in FHIR (or for that matter, any EHR columns that has no FHIR corresponding match). There is no corresponding FHIR Resources or FHIR elements that we can map to on the FHIR Server.
Since there is not a single FHIR resource that captures any or all of the EHR Attribution Column name above, we cannot create an extension. Other option could be, to create a new ATTRIBUTION resource in FHIR. In the interim, how do we expose the EHR Attribution Column names (1-5) to consuming FHIR clients and 3rd party? Should we use the same EHR Attribution Columns names (1-5) and mention in the capability statement as non-FHIR complaint elements? Please let me know?
Lloyd McKenzie (Jun 24 2019 at 23:04):
Can you explain what attribution means?
Roney A (Jun 25 2019 at 17:47):
Can you explain what attribution means?
The attribution entity and/or attribution implies it contains PCP and Payer attributed to member for every month.
Roney A (Jun 25 2019 at 17:51):
Can you explain what attribution means?
The attribution entity and/or attribution implies it contains PCP and Payer attributed to member for every month.
Hi Lloyd, just sent you the definition. Importantly, there are two questions? First do we recommend to the FHIR committee to create another FHIR resource for ATTRIBUTION? Secondly, in other similar scenarios, how do we map so many EHR columns to FHIR, if there is NO corresponding match in FHIR resource and elements. Do we publish, it as non FHIR conferment columns?
Lloyd McKenzie (Jun 25 2019 at 17:55):
Reading that definition doesn't help me understand. What does it mean for a payer to be "attributed" to a member?
Roney A (Jun 28 2019 at 16:32):
Reading that definition doesn't help me understand. What does it mean for a payer to be "attributed" to a member?
Hi Lloyd, The word "Attribution" may be confusing , for simplicity, consider the word "association". Attribution or "assignment" is a key program methodology used to identify the members associated with a PCP and Payer during a course of time, preferable over a period of month. This helps maintains history and help us derive several measures. Not necessarily Paid for Value, PMPM, etc.
Refer to CMS patient attribution:
https://www.aafp.org/fpm/2016/1100/p25.pdf
Refer to CMS patient attribution model:
Refer to CMS two-step attribution process:
Lloyd McKenzie (Jun 28 2019 at 20:28):
I'm going to poke @Paul Knapp @MaryKay McDaniel and @Andy Stechishin - this is U.S.-specific and I'm not sure what the expectation is for how they're represented.
Roney A (Jun 28 2019 at 20:53):
I'm going to poke Paul Knapp MaryKay McDaniel and Andy Stechishin - this is U.S.-specific and I'm not sure what the expectation is for how they're represented.
Thank you Lloyd, and I understand. In the interim, I need to revert back to my second question iterated in several chats: Till the matter of "ATTRIBUTION" is under review with FHIR members, how do I represent/expose ATTRIBUTION API's as JSON objects in FHIR server? Will other parties understand these non-FHIR resource "ATTRIBUTION"? and perform GET, PUT and POST?
In other similar scenarios, how do we map so many EHR columns to FHIR, if there is NO corresponding match in FHIR resource and elements (for example, "ATTRIBUTION"). Do we publish, it as non FHIR conferment columns?
Lloyd McKenzie (Jun 28 2019 at 21:52):
If we can't find an appropriate home for an element, you can use the extension mechanism to capture pretty much whatever you can imagine. (But it's better to use core elements whenever appropriate.)
MaryKay McDaniel (Jun 29 2019 at 00:46):
Hi Roney A,
I'm trying to understand your questions, but my 1st question back to you is where are you getting these data elements from? You are calling these EHR columns - are these fields out of some EHR somewhere?
Thanks.
Mary Kay
Andy Stechishin (Jun 29 2019 at 04:26):
@Roney A could you explain the business purpose that you are trying to achieve? It appears from your descriptions of the 'Attribution' that they appear tied to some kind of enrolment in program. But I am only guessing without further information
Andy Stechishin (Jun 29 2019 at 04:28):
@Roney A would you mind attending a Financial Management teleconference to discuss the additional Pharmacy Claim columns?
Roney A (Jun 29 2019 at 20:36):
Roney A could you explain the business purpose that you are trying to achieve? It appears from your descriptions of the 'Attribution' that they appear tied to some kind of enrolment in program. But I am only guessing without further information
Best, and is critical to go over the CMS mandated requirements, understand their business definition, and align accordingly to FHIR. ATTRIBUTION is very well articulated by CMS.
Refer to CMS patient attribution:
https://www.aafp.org/fpm/2016/1100/p25.pdf
Refer to CMS patient attribution model:
Refer to CMS two-step attribution process:
Roney A (Jun 29 2019 at 20:49):
Roney A would you mind attending a Financial Management teleconference to discuss the additional Pharmacy Claim columns?
Before I commit, could you please list those Pharmacy Claim columns in question? I may have listed a few, and lost track of it, as there was no corresponding match in FHIR. Pharmacy claim and PBM both are huge subject areas and impact the financial model through Claims.
Roney A (Jun 29 2019 at 20:56):
Hi Roney A,
I'm trying to understand your questions, but my 1st question back to you is where are you getting these data elements from? You are calling these EHR columns - are these fields out of some EHR somewhere?
Thanks.
Mary Kay
Thank you Mary. As mentioned earlier, these are the Column fields that are captured in any major EHR enterprise data model, that captures pharmacy claims, dental claims, institutional claims, and professional claims, -837i, 837p, & 837d, PBM, etc, and much more... Strongly, recommend to review the CMS links around the "ATTRIBUTION" entity. It is self explanatory and poses a strong need to establish a resource name "ATTRIBUTION" in FHIR.
Roney A (Jun 29 2019 at 21:00):
If we can't find an appropriate home for an element, you can use the extension mechanism to capture pretty much whatever you can imagine. (But it's better to use core elements whenever appropriate.)
Thank you Lloyd. Agreed. It does imply, that if we choose to use "extension mechanism" we would not directly tie it to the resource "ATTRIBUTION", as it does not exist in FHIR. We have to use extension mechanism, across multiple meaningful FHIR resources and split the attribution columns accordingly. Assuming, that is the correct understanding?
Lloyd McKenzie (Jun 30 2019 at 15:10):
There is no "attribution" resource. There are resources that reflect enrollment, elligibility, membership in a care team and a variety of other things. I suspect that some aspects of the concept of "attribution" will turn out to fit in one of those places - but leaving it to those who are more familiar with CMS and U.S. claims processes to evaluate the 'where'.
MaryKay McDaniel (Jul 01 2019 at 15:45):
Attribution is US Realm centric enrollment item. Some plans 'assign' a member/patient/recipient to a particular Provider up front (PCP or specialist or both). In other cases, the Provider is assigned based on claims submitted.
Roney A (Jul 04 2019 at 21:49):
There is no "attribution" resource. There are resources that reflect enrollment, elligibility, membership in a care team and a variety of other things. I suspect that some aspects of the concept of "attribution" will turn out to fit in one of those places - but leaving it to those who are more familiar with CMS and U.S. claims processes to evaluate the 'where'.
Thank Lloyd. It makes sense.
Roney A (Jul 04 2019 at 21:49):
Attribution is US Realm centric enrollment item. Some plans 'assign' a member/patient/recipient to a particular Provider up front (PCP or specialist or both). In other cases, the Provider is assigned based on claims submitted.
Thank you MaryKay. I agree.
Paul Knapp (Jul 12 2019 at 17:26):
@Roney A @Lloyd McKenzie I would expect that the attribution list, a roster, would be a Group of patients. I would start looking at Group and then see what is missing from that perspective.
Roney A (Aug 14 2019 at 16:27):
Hi Lloyd, how are we addressing the challenges of creating FHIR APIs between different EHR FHIR versions running R4, R3, and/or R2? Not clear how the CapabilityStatement /fhirVersion mime type parameter will address the conversion? Do we need to write a conversion routine for all the different FHIR versions? Or, do we create different end-points for different versions to address change between versions of FHIR? Please let me know?
Lloyd McKenzie (Aug 15 2019 at 04:26):
@Roney A please re-ask on the general #implementers stream as this question has nothing to do with CCDA conversion. (Also look at the r4 spec page on versions that tries to address this very question.)
Last updated: Apr 12 2022 at 19:14 UTC
